7 Costly Mistakes To Avoid When Submitting a Provider Appeal

When you file a provider appeal and receive a decision for no additional payment, do you ever wonder if there was something else you should or shouldn’t have done that could have led to a different result?

The appeals process is the last effort to get claim lines paid. Depending on the nature of your appeal and the health insurer, it can also be one of the longest & most tedious processes. To top it all off, it can be difficult to get substantive feedback regarding the appeal process itself or if there was something you should have done differently.  Here are 7 common mistakes to avoid. 

  1. Appealing everything

The most common misconception is that ALL denials are eligible for appeal. Before you start down this road, check the health insurer’s provider guidelines to determine exactly how a provider appeal is defined.  Generally, administrative denials – failure to obtain authorization or not submitting a claim timely, etc. – are not eligible for appeal review. Yet surprisingly, they tend to account for close to 50% of the correspondence that comes into an insurer for post-service review. And guess what? For administrative denials, no matter how compelling your letter is there’s a 99.9% chance it’s not going to be reviewed in-depth. Bottom line, if it doesn’t qualify as a provider appeal, don’t waste your time sending it through the appeals process. 

  1. Calling customer service

Customer service representatives are trained in many things, typically, appeal reviews are not one of them. You might encounter a savvy rep who can look at claim policy or medical policy and make a correct determination, but understand this is not the norm nor is it a part of their assigned duties. Additionally, customer service reps are not authorized to make payment decisions. So even if they determine that a denial should be paid, their scope is limited to requesting the adjustment.

  1. Submitting corrected claims for denials that need review

On the surface, this seems like a good idea. If a claim line is denied, simply update a procedure code or add a modifier as a test to see if it will pay. It’s less time consuming than gathering all the documentation to submit an appeal and the response time is faster. Here’s the problem with that – corrected claims is an electronic process, no one is looking at it & manual intervention isn’t likely. If the line remains denied, you’ll still need to file a provider appeal. Worse yet, other lines could reprocess, edit against each other and cause more lines to deny. Not only that, when it finally goes through the appeals process, the reviewer will see the same service billed multiple times.  It’s confusing and can negatively impact the chances of getting the appeal in question overturned. 

  1. Sending incomplete documentation

The most overlooked part of the appeal submission process are the medical records. They should correspond to the date of service, but also any associated services (pre or post) that would lend further insight into the case. You want to avoid the potential delays that come with having to send documentation back and forth regarding the same case.

  1. Not sending the appeal to the correct place

Make sure your appeal is addressed to the correct area (P.O. Box, floor, unit, etc.). There’s nothing worse than a piece of correspondence floating throughout a company. The larger the company, the greater the chance your appeal will not get to the correct department timely or with all the original documentation.  Check your provider guidelines for each insurer, as location can vary based on denial type.

  1. Not knowing the appeal process

Once you’ve filed the appeal, what happens next? Who is reviewing the appeal? What is the level of expertise – coding, clinical? How many levels of review are there? What are the timeframes for review? Is the process the same at each level of review? What guidelines and policies govern the process? Knowing these elements will help you set expectations around your appeals. 

  1. Ending at the uphold/overturn determination

Now you’ve got a decision in hand. Good, bad, or indifferent, case closed, right? Wrong! Unfortunately, it’s not enough to only know whether your appeal was upheld or overturned. You need to understand why. Knowing the root cause of the initial denial will help your office identify gaps in the process (i.e., billing,, reviewing policy, etc.) and make better appeal decisions. 

The definition of a provider appeal will differ between insurers, so make sure you know the rules for each one. The following apply regardless of the health plan. 

  • Make sure your claim denial qualifies for appeal review
  • Send a complete request to the appropriate area
  • Understand the end-to-end appeal process
  • Examine whether there are lessons learned regarding how you handle future claims with the same denial